EFFECTS OF CHILD ABUSE ON PERFORMANCE OF PRIMARY SCHOOL IN KAPYEMIT WARD, TURBO CONSTITUENCY, UASIN-GISHU COUNTY.





BY
ERICK NYAKUNDI
KIS/03013/14




A RESEARCH PROJECTSUBMITED TO THE SCHOOL OF ARTS AND SOCIAL SCIENCES, DEPARTMENT OF SOCIOLOGY AND PSYCHOLOGY IN THE PARTIAL FULFILMENT FOR THE AWARD OF THE DEGREE OF BACHELOR OF SOCIOLOGY



MAY, 2014

DECLARATION

I, the undersigned, declare that this project is my original work and that it has not been presented in any other university or institution for academic credit.

Signature...............................................­..... Date...................................
ERICK NYAKUNDI
KIS/03013/14






SUPERVISOR
This project has been submitted for examination with my approval as university supervisor
DR. W. O. ABUYA
Signature..................................................­.. Date....................................




DEDICATION
I dedicate this work to my Dad, Mom, my sister Lydia and my lovely brother Dun who contributed in one way or another to make this project to be successful.


















ACKNOWLEDGEMENT
I would like to thank all individuals who contributed and sacrificed their time towards completion of this project.
To my supervisor, for the guidance and support in the development of this research project, His advice and criticism made this project what it is.
Thanks to colleagues and friends for their suggestions, advice and encouragement. To all of you may God bless you abundantly for your tireless effort.

TABLE OF CONTENTS
Contents Page
DECLARATION i
DEDICATION ii
ACKNOWLEDGEMENT iii
TABLE OF CONTENTS iv
LIST OF TABLES vii
LIST OF FIGURE viii
ABSTRACT ix
CHAPTER ONE 10
STUDY OVERVIEW AND STATEMENT OF THE PROBLEM 10
1.1 Background of the Study 10
1.2 Research Questions 13
1.3 Research Objectives 13
1.4 Justification of the Study 13
1.5 Significance of the Study 14
1.6 Scope of the Study 15
1.6.1Assumptions of the Study 16
CHAPTER TWO 17
LITERATURE REVIEW 17
2.1 Introduction 17
2.2 Common Forms of Child Abuse 17
2.2.1 Child ****** Abuse 17
2.2.2 Physiological or Emotional Abuse 17
2.2.3 Physical Abuse 18
2.2.4 Child Neglect or Abandonment 18
2.2.4.1 Physical Neglect 19
2.2.4.2 Educational Neglect 19
2.2.4.3 Medical Neglect 19
2.2.5 Child Fatalities 20
2.3 How Child Abuse Affects Academic Performance 20
2.3.1 Child Abuse and Academic Performance 20
2.3.2 Child Abuse and School Image 23
2.3.3 Child Abuse and Dropout Rate 25
2.4 Strategies that Schools can Employ to Curb Child Abuse 26
2.4.1 Role of Public Regulation 26
2.4.1.1 Nurturing and Attachment 27
2.4.1.2 Social Connections 27
2.5 Theoretical Framework 27
2.5.1 Learning Theory 28
2.5.1.1 Relationship with the Study 28
2.5.2 Family Dysfunction Theory 29
2.5.2.1 Relationship with the Study 29
CHAPTER THREE 30
RESEARCH DESIGN AND METHODOLOGY 30
3.0 Introduction 30
3.1 Site Description 30
3.2 Research Design 30
3.3.1 Target Population 30
3.3.2 Sample Size and Sampling Procedure 31
3.4 Description of Research Instruments 32
3.4.1 Research Instrument 32
3.4.1.1 Questionnaire 32
3.5 Data Collection Procedure 32
3.5.1 Validity and Reliability of Research Instruments 33
3.5.1.1 Reliability of Research Instruments 33
3.5.1.2 Validity 33
3.6 Data Analysis and Presentation 33
CHAPTER FOUR 35
DATA PRESENTATION AND ANALYSIS 35
4.0 Introduction 35
4.1 Background Information 35
4.1.1 Age of the Respondents 35
4.1.2 *** of the Respondents 35
4.1.3 Education Level of the Respondents 36
4.1.4 Marital Status 36
4.2 Specific Information 37
4.2.1 Effects of Child Abuse on Academic Performance 37
4.2.2 How Child Abuse Affects Dropout Rate of Students in School 38
4.2.3 Proposed Strategies that Schools can Employ to Curb Child Abuse 41
CHAPTER FIVE 43
SUMMARY, CONCLUSION AND RECOMMENDATIONS 43
5.0 Introduction 43
5.1 Summary of the findings 43
5.2 Discussion of the Findings 44
5.3 Conclusion 45
5.4 Recommendations 46
REFERENCES 47

LIST OF TABLES & FIGURES
Table 3.1 Target population 32
Table 3.1 Sample size 33
Table 4.1 Age of the Respondents 36
Table 4.2 *** of the Respondents 37
Table 4.3 Education Level of the Respondents 37
Table 4.4 Marital Status 38
Table 4.5 Effects of Child Abuse on Academic Performance 38
Table 4.6 How Child Abuse Affects Dropout Rate of Students in School 40
Figure 4.1 Views of the Pupils on Abuse 41
Table 4.7 Proposed Strategies that Schools can Employ to Curb Child Abuse 42





















ABSTRACT
Child abuse is the physical, ****** or emotional maltreatment or neglect of a child or children. The consequences of child maltreatment can be profound and may endure long after the abuse or neglect occurs. The purpose of the study was to investigate the effect of child abuse on school performance in Primary Schools in Kapyemit ward, Uasin-Gishu County. The objectives of the study were: To assess the impacts of child abuse on academic performance; to determine the effects of child abuse on schools image, to identify the impacts of child abuse on pupil drop out rate, to investigate the effects of child abuse on pupil transition rate. The study employed a survey study design. The study targeted 160 respondents which includes; 5 Head Teachers, 40 Teachers, 70 Pupils and 35 parents of which a sample size of 48 was obtained from using 30%. Purposive sampling technique was used in selecting the head teachers while simple random sampling technique will be used to select the teachers, Pupils and parents who formed the respondents of the study. Questionnaires and interview schedules were used as data collection instruments. Data was analyzed quantitatively and qualitatively and presented in form of tables, percentages and frequency. The study helped in the understanding of the effects of child abuse on the school performance, the realization of the roles parents and teachers play in the curbing of child abuse among pupils and raising awareness on the same.
 
CHAPTER ONE
STUDY OVERVIEW AND STATEMENT OF THE PROBLEM
1.1 Background of the Study
Child abuse is the physical, ****** or emotional maltreatment or neglect of a child or children. The consequences of child maltreatment can be profound and may endure long after the abuse or neglect occurs. The effects can appear in childhood, adolescence, or adulthood, and may affect various aspects of an individual's development (e.g., physical, cognitive, psychological, and behavioral). These effects range in consequence from minor physical injuries, low self-esteem, attention disorders, and poor peer relations to severe brain damage, extremely violent behavior, and death. In extreme cases, child abuse affects the performance of schools in the affected region (Daniel, 1978).
Performance refers to how students deal with their academic studies and how they cope with or accomplish different tasks given to them by their teachers. Performance is also the ability of a school to portray a good image which can influence the public (Decastro, 1978). There are several factors that influence the performance of a school at large, however, there is a critical factor that most researchers have avoided to discuss, and child abuse has been a crucial factor that has contributed to children’s dismal performance. Apart from children’s personal intelligence, child abuse is among then key factors contributing to poor performance of learners. Child abuse can lead to school dropping, emotional trauma or can even be fatal, hence destructing or even terminating the educational ambitions of a child. (Harris, 2005)
Worldwide, according to World Health Organization (WHO, 2000) approximately 40 million children are subjected to child abuse each year. According to Human Rights Watch (2001) about 30% of all severely disabled children relegated to special homes in the Ukraine died before they reached 18 years of age. UNICEF estimates that two million children died as a result of armed conflict during a recent 10-year period and that another six million were injured or disabled. In Canada, the U.S. and Mexico, over 6.5 million children annually are exposed to unwanted ****** materials over the internet; over 1.7 million of these report distress over exposure to these materials. In the United States, the Centers for Disease Control and Prevention (CDC) and the Department for Children and Families (DCF) define child maltreatment as any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child. Child abuse can occur in a child's home, or in the organizations, schools or communities the child interacts with. Each year, approximately one million children around the world are introduced into commercial ****** exploitation despite this problem; these developed countries have put measures to curb the vice. Rehabilitation schools have been formed and introduction of counseling centers as well. Despite the prevalence of child abuse in this developed nations they narrowly affect the academic performance since there are organizations put in place to curb the situation e.g. child associations, guidance and counseling institutions, and school based counseling programs (Giles, 2001)
Concern for victims of child abuse in Africa expressed by the African network of the International Society for The Prevention of Child Abuse and Neglect (ISPCAN) which gave five main presentations of child abuse: child labor, street wandering, ****** abuse, child battering and abandonment (Elma, 1977). Child labor according to the international labor organization (ILO), about 10 million children less than 15years in Africa are in formal employment, working long hours with poor pay and are exposed to substantial health hazards. Wandering of children refers to children, usually unkempt and with delinquent propensities, living rough in town. The reasons for children taking to the street remain poorly understood particularly in relation to factors in the child rather than parental hostility and economic (Dubowitz, 2002)
****** abuse is another. For example, arranged under-age marriages are common in some parts of the continent and doubt was often expressed as to whether a young girl fully gave consent to being betrothed (Galdsone, 1965). Prevalence rates in Africa are very difficult to ascertain because of the fear of disclosure by victims and lack of proper documentation. Most of the girls by reasons of shame fear or surprisingly respect for their usually older perpetrators. Physical battering is also eminent. Physical abuse of children is widely claimed to berate in the third world; however, there are anecdotes from east Africa skeletal frame or localized body areas of all first attendees aged 0-12 years at this hospital during the four-year period 1 January 1987 to 31 December 1990 (Garbarino, 1975). Sixty-nine of these reports reveals evidence of multiple bone fractures wither without evidence of rib or skull fracture. Abandonment of children to roam around the streets in what we call street children is also eminent in Africa, though valid and adequate information on abandonment are difficult to obtain due mainly to failure of offending parents to show up out of guilt, shame, judicial repercussions or a combination of these. However, some euro-American missionaries identified inter alia breech birth. (Erickson, 2003)
Child protection measures in Kenya are currently not implemented effectively and fully (Galdstone, 1965). Compliance with such legislation would increase if the magnitude of the problem and better knowledge about the factors that put children at risk was available. Additionally, involving stakeholders, especially agencies charged with protection, as well as involving affected children, will highlight the issues and thereby promote adherence to protection policies. Kenyan children, child activists and children organizations are pinning their hopes on the implementation of the Children’s Act to improve the lot of the nation’s youth. The Act, which came into effect on 1 March 2002, puts in place full safeguards for the rights of the child. Its passage was a giant stride in harmonizing the national laws with international agreements which Kenya has signed such as the UN Conventions on the Rights of the Child (CRC, 2002)
There is hope that the new legislation will dramatically change the inattention, neglect and abuse towards child rights. The Act outlaws any form discrimination of children, and forbids Female Genital Mutilation (FGM), child prostitution, and child labor, among other forms of abuse. The Children’s Act has immensely improved the lives of many Kenyan children plagued with high illiteracy levels, frequent **** cases and child labor since it guarantees children the right to health and medical care, provision of which is the responsibility of the parents, the extended family and the government (Erickson, 2005).
Cases of child abuse in Uasin-Gishu region have been so eminent in the recent years ((Kenya Media Report, 2004). In the year 2010 and the year 2011, there was a program started to rehabilitate this behavior. This problem is clearly evident when you first arrive in Eldoret town, it is among the towns in the country with the highest number of abandoned children who keep on moving from one Centre to another seeking help from passersby. Parents have developed behaviors of abandoning their children and deliberately sending them to the town so that they can benefit from their borrowing. So to say this has led to child labor in this region. High profile cases of school dropouts have been recorded regarding the environs of this region. Young school children from different locations in Eldoret converge in town to persuade people to offer them financial assistance. Some attend school in numbered days and decide to spend some good number of days out of school.
The communities and societies around tend to assume this situation and term it as norm. A few who might seem concerned lack cooperation from the rest. This has adversely affected the performance of most of schools, hence leading to poor living standards of the people and a poisoned future of a young citizen. The problem has affected learners in regions like many areas in Uasin-Gishu County. It has really affected child development and affected their attendance and performance in school. Little intervention measures has been taken to advocate the holistic development of the children. It was to this reason that the researcher conducted the research in the named above region
1.2 Research Questions
The study was guided by the following questions;
1) What is the effect of child abuse on the academic performance of students in Kapyemit Ward?  
2) What are some of the proposed strategies that schools can employ to curb child abuse?
1.3 Research Objectives
The study was guided by the following research objectives;
1) To identify the effect of child abuse on the academic performance of students in Kapyemit Ward.
2) To identify proposed strategies that can be employed to help curb child abuse.
1.4 Justification of the Study
It is becoming increasingly difficult to separate child abuse prevention into separate categories. For instance, strategies on the societal level include increasing the “value” of children, increasing the economic self-sufficiency of families, discouraging corporal punishment and other forms of violence, making health care more accessible and affordable, expanding and improving coordination of social services, improving the identification and treatment of psychological problems and alcohol and drug abuse, providing more affordable child care and preventing the birth of unwanted children.
Very little analysis has been done to estimate the total cost of preventing child abuse and neglect or the long-term social costs of not preventing it. There is now a move to situate child abuse and neglect within the continuum of intervention which addresses multiple aspects of family behaviors. The efficacy of tackling portions of the problem of child abuse apart from broader societal needs is not known. And, perhaps prevention can only come in tandem with efforts to reduce poverty, improve health care and make children’s issues a national priority. However, despite these constraints, evaluations of prevention programs can be improved by coming to terms with definitions of key varia

Floating above the rifts of apperception I glaze over the gaudy faucets of imagined vector thrusts in hibernation by the lucubration of space-time materialized crystal in the somber beats of fetched farrago of choice slices in delicate hums of hemmed balance rantipole only in ethereal importance but otherwise supersolid above the sprauncy vagrancy of dilettantism. We shout a clarion virtuosity so that the conclamation of neovitalism conjures upon a spell of lapse and regress a motive for further crystallization of epidemiology into harmony with syndicated admonition sleek in design and parceled into renown by feats of completion rather than slugabed gregarious fountains of wasted ingenuity bleeding from the vacuum of an empty hearth in a hospitable dwelling otherwise cleared of imperfection. Right now, I levitate with transcendence with an approximated eidetic memory that is the surgical vibrancy of renewal rather than the chameleons of hidden talents buried by the walls of Jericho sounding tocsins of alarm that the anointed favor of choice destruction is only an encircled rapture of rhapsodies of confluence found in axiomatic truths ribbed with the futtocks of seaworthy but cauponate recidivism into the donnybrooks of apocryphal revelation preceding the whimsical fall of cascading permanence just as gravity so ordained it. We breathe the life of the ethereal numinous spirit of isangelous repute because we navigate the exquisite cobweb of reconciliation to surpass all understanding in peace what would be a miscegenated carcass of war otherwise apart from the incidental apartheid of the drones of causality ignoring the antecedent reality too much to register fathomed streaks of preventive endeavor because of the scars of a scrappy schlep of the rampicks of ecbolic servitude to moth-eaten star-crossed lovers of the mean menagerie of gutless succor renowned only in tepid rejections of harbingers bequeathed in succession but ignored because of the procession of “Billie Jean” politics.

   The citadel aflame with controversy buttresses carnality by witless contaminants of hidebound scaldabancos of ineffable destitution so craven in eisoptrophobia for their hypostasized indolent fatuousness of capitulation that they are but a minor punctuation in the largesse of centuries to favor audacity in candor over the prevarications of catastrophe to dented human pride against humane dictates of theodicy in fatalism that predestination experimented with its own vaulted verve to find permanent solutions engraved in the agrapha of time to solidify the redintegrated truth of God’s divine stewardship above the quisquilous deism of former regnant centuries of blench and blandishment. We revolt at the specter of rot only when the effluvia of disgust elevates the visceral reality above the utilitarianism of recycled prim nuisances of noisome lineage that yet balk because they are bereft of attention but not a vacant talent and therefore should the subsidies of man surpass the ignorance of appearances he will shrug of the demur of the scrimshank and sharpen his scrivello in the service of redemption found through cultivated prowess of gardens beneath where rivers flow above a cubic centurion of embattled visages of the heavens becoming the rampart for the vestigial clarity of Secret Masters to foresee the bypass that heals decadence and rebukes the formalism of puritan endeavor to sweat with exhaustive patience over the gossamer intertesselations of a ripe reality rather than a groveled fragmentary world shattered too much by exigent metanoia to mount the crenellated catchpole of vigilant enmity towards the stew of listlessness found in epigone and farce more than in organic fortunes. We flip the upheaval of society to squander our proportionate degrees of wealth on the necessity created by dire quandary which enamors by interrogations of pulchritude the verisimilitude of participle ivory dalliance of etched canvasses of simultagnosia for the librations of the liberated rings of betrothed liberation despite profound lurches of the mistetches of ignorance presiding dismally over the hulked disdain of glamborge rather than resselenque.

     The winter is a poor porcine glut of ciconine swelters because the prickly obtuse recoil of the delopes of caution find their permeable balance with a sort of photographic photosynthesis that braves the dearth of reprieve for the reprisal of nostalgic deeds found in the docimasy of riveted reflections because the preordination of God is the superlative champion of the witeless grandeval protectorate of infinite concepts guarded from the parvanimity even of the most strident minds squabbling over the braseros and battues of history as though those funereal stains of lachrymose regret outweigh the traditions of vaunted human progress because they are finicky about importunate pleas of subsidiary injustice rather than fulminations of the modern rebuttal to the disclaimers of an uneven history that shepherds the doubts of nihilism into ripe fruition at the expense of very expensive moral rot for the codlings of urbacity and mendaciloquence used to foment that tribalism of totemic justice. We see in Penuel the wrestling match of specters and heroic giants documented on the ageless pages and we notice the ironic twinges of struggle that kneaded the propriety of gentilian privilege that ultimately fostered an insurrection against chosen bravado among those that sear with zeal beyond the yordim afflictions of yobbery because the Jewish heart is stronger than any calamity even if it departs from the reverence of the colporteurs of the integrated syncretism of the attempted monolith that beseeches polyphiloprogenitive growth in mindset rather than in testy abeyance of forbearance because of known scrutinies into the tropology of wilted facts remanded by curious historicity that crumples without disdain when we memorialize the erasure of scepsis by modern standards of thaumaturgy.

    The minauderies of growth are a repositioned tacit allegiance to the untold fanfare and hearsay immunized against the broach of facetious levity to buoy discordant hearts above fumatoriums of relentless ignorance because coherent masterwork can be cobbled without such lapidary toil and toll on sincere affectations of wizened brevity. The seismic precautions for the forefathers of incidental convergences between expectancy and crystallized history are an ironic intortion of priorities because the heralds and tribunes matched the peerless foresight with the gerrymandered figments of apartheid between the imaginary and the real so that the delicate synchrony of events could unfurl a riveting carapace from the shells of protection even in amiable squalor for its impenitent attrition on the volleys of sensible rumor becoming fashioned in covert bedazzled errors in judgment leading to the triumph of the eventual civilization over the futtocks of the burial of the former trekleador of zenkidu belonging to provincial cadasters found so tucked in the hedges that discernment of frikmag would be an indelible scourge on the biognosy of the diagnosed endeavors that elapsed into remediated circumstances that brave the depths of deontological violation for the breadth of apportioned loaves and two swanky fish earning a place among the miracles of transcendent liberation from articles of decree imperious by sardonic disdain becoming nullified by the histrionics of a delicately staged orchestra that cements human achievement.

       We relish the frescades of a ruffled autumnal reminder of flourish above pothers of the screed of admonition swamped by nostalgic backtracks in the séance with ultimatum of design and the impregnated and carnal lusts of a world pitched in darkness with guarded lambent lights fomenting a perjury against tact for the deliverance of freedom in tacit agreement with owleries that every bonanza be tithed in their favor regardless of hibernation of spoilsports or their subsidiary remarks on indelible quills of invented manufactured realities we crave with desperation rather than cower from in requited nescience urging us to depart from affairs and stagnate the loyalty of fealty above the limber of utility mobilized above levities for solemn remarks and rejoinders. Promulgated above the robotic rubble of staffage haywire in wiredrawn contemplative resonance of tremulous subterfuge vestigial but immediate to the yardsticks of reprehensible malarkey, is the barnstorm for erratic dimples sauntered by the saunas of shelter above the chaos of ruined ginnels for the gimcracks of auxiliary duty to service, is the glorification of the sultry intimations of legions of remonstrance in guarded decorum about sunken atrocities lapsed in memorial to the incumbent brunt of sockdolagers of justice returning revenants from the bridewell of historical internment. The symphily of orchestras to cineaste symposiasts of surquedry in impudence beyond the brays of betrayal is the aborning mythos of regimented perceptions of a world that when magnified by minutiae appears starkly contrast to the gapped gubbertushed reality of the average patron of the arts to such an extreme gulf of receptive understanding that the qualia are dovetailed only in the swink of careful kisswonks to certify certitude itself when all the fragments coalesce into subjoined harmony to the substructures of inherent conscientiousness. The miracles at work that are vesicles and vessels for the swage of imprint above the loyalty of the imprinted tribunes of the fluminous is how hidden protrusions can emerge so victorious over popularized glazes on the pastures of a farmed culture itching for timmynoggies of innovation but only finding the etched remarks of pristine imagos of heroism dwindling in motivation to surpass the imaginative leaps accustomed to a newfangled laziness that bedazzles the guzzle of crowds but not the discrimination of the crowded morass of incompletion found in mosaics missing enigmatic philters of intoxicated love for the profound. So to be intermediary as a custodian for artistry we must cozen the wheedled imaginations not of the relic but the archaeologist that discovered the embedded prisms of attentive scrutiny for glinting sunshine inherent in troves of surpassed excellence beyond parochial sympatric blandishment of donnism rather than a resselenque that floats above demeanor to usher the cosseted age of treasure above the glib brocards and florews of past success.

      Immanent to the provisions of God as decreed from a syncretic reconnaissance of the pitiable gulfs that separate boundless divine love from the clavigerous potential for scrappy sympatric affiliation to **** through the barnstorms of internal comestions of conflated priorities we are ourselves prismatic in the indulgence of a tasty life sprinkled with zest rather than tempered with the vengeance of retorted animosity that we knead the pottery of ironclad resistance to a metallic conduit of pruned fulminations of unguided intuition so that the natural accord supersedes the goad of materialism for the sustenance of antiquity beyond its heyday for vital gains against the tauricide of panic and frenzy. The linchpin of all realistic attempts at the sympatric symphily of civilization is a guided remorse through the torment of affliction that sizzles without anteric barbs as it measures through engrenage how to pilot the vehicles of prosperity through the minefields of contingency that invisibly bequeath new hurdles and inestimable obstacles that collude surreptitiously to fulminate measured controversy against the backbites of restrained equipoise created by polities of the macadamized fabric of a welded smithy of a universe that with ubiquity proclaims above the senseless the harvest of conjugal repartee in sensible pride against militant bastions of incidental prejudice for a careen against the flyndresques of danger and the flyndrigs of glaikery alike for a humane spurt of enlightenment to tower peerlessly in supervision of entelechy created by esemplastic unity in apolaustic purpose. We cannot be puritans engaged in a pilgrimage to a palimpsest of priggishness because the daring elements of adventurism are necessary ingredients to catalyze the supply-chain of the innate gluttony of ego-seeking endless balance with a natural sustained biognosy that prizes biocentric harmony above bibliognost scepsis so that the enthused can flock with liberty divorced from libertinism. The ultimatum is a war between hedonism wed with donnism against eumoirety and self-restraint and this battle will be waged on the indolence of a future of cordslave tethers to interrogation of privy conceptualism hamshackled by the gradgrinds into the neat nexility of precise conformity that blacklists the samizdat because the genizah profoundly twists the already jumbled jengadangle and provides a junediggle of procession and ceremony rather than pomp without substantial grit embedded in the showmanship of a reality in need of a fourth-wall.

        It is ironic how we bewrayed our stewardship of the planet as a plenipotentiary sentience waged against the vesicles of instinct but more fundamental to this tattered but pregnant psalm is that the stronghold of our future is the tenacity of filial duty to enthrone the household with husbandry and restraint as an emolument to divine justice that sparkles opalescent in its own redacted notions of gravity imperfect in the taradiddles of science but refined by the eclat of the combustible syncopation of a reiterative trope of realism combined with surrealist caprice to henpeck affectionate violation above inviolable screeds of blood sport rather than conjugal affections afforded to the brood and the feast of the flocks that rein supreme over all things but exert inclement justice over the cattle and chattel of civilization itself. The minkumpf against the sacrilege of a prioritized kosher is to abhor the suffering rather than embrace the penitence of perceived but specious sacrifice which is an ornery thorn on the stained conscience of the yobbery of both the apikoros and the obedient because to attenuate all suffering even of instinctual beings we anneal our hearts to a glorified compassion that supersedes the relegated relics of pushful genuflection by succedaneum of sacrifice waged against the docile whangams of otiose theodicy. The filibusters against the regnant complexity of regalia that is a sprauncy poivrade with terpsichorean flairs to transmute the intimations of hibernated perfidy into finicky transmissions for the riometers that accord orbific merit in a lackluster time enchant the rollicking audience of this auditorium of the prevenance of the conquered universe bracing for the camorra of the insipid entreaty of defalcated casuistry—the prominent exchequer in hoodwinked political agitprop that forges ironclad allegiances to flimsy facades of the verisimilitude of dignity with recalcitrant but incondite bruits of venom militant against secular apostasy—that the fitful arrivistes that swim in dire dearth will be welcomed into the reconciliation of all time with a tempered lurid glint of revelation bounded by sunken albatross of hype unbounded with a peace insurmountable in prestige rewarded only with the highest reservations.


    On 3-1-2020 when I penned my philosophy—even at a slowpoke margin of crafty precision above rapid empirical faucets of folly—I was entirely selfsame with the autotelic engravings of the smoldering aboriginal talents within that many can swing through by tenacity for enormous plaudit but a flagrant majority will apprehend with flippant scollardical tenets of rebuke and remain honest in their appraisal only in meek resignation of parvanimity.
Consider the postulates of rarefaction whittled into a vehement zeal against the prostitution of our species to the anteric cycles of residual molds of dingy spectacle mired by the tyrannical towers of supercilious squirms of revamped novelty rather than enhanced by the freebooters of dirigisme that borrow from time the behest of philandered flairs divorced from the cadges of secular instinct and enthroned by the qualms of engineered virtuosity that is stark, barren but peerless in its outstretched clamor for luxuriant sprees against the silentium of grandeval asylum incurred by the flippant filigrees of recalcitrant modernism endangered by the irredentism of the future upon the whimsy of the present-minded momentary glare of rapture.  This impending architecture of nimble but subservient endeavor is a pinprick rejoinder against the wernaggles of prepossessed fountains of configured animosity against the stapled heed of a modality of trayned invictive invectives against the plodding course of fustilugianation that swerves in apathy of autopilot junediggle to emanate the surrender of epigone to the raktendure of the synaesthesis of the attuned perception of all superimposed minutiae delegated by calculated design into a synclastic focus on veiled caprice that is vaulted above the choppy and sketchy verdure of remiss perception to stellar continuities rather than mundane knickpoints of stodged blurs that magnify syncretic qualia into baseline congruity rather than staid torpefied resignation of the visage of thunder without the pangs of the widely vituperated lightning that bequeaths all certain notions but flouts the tortious saboteurs of the prim trucage of brittle fundamentalism.

     As the flawed paragon of a picaresque youth punctuated by vibrant plumage of self-wrought tropophilous usucaption of remote groomed frontiers of desolate luxury but buoyant morale into the ballasts of a nimble usufruct that hikkles yet still against still-framed thilloire--fatuous in endearment only to the polity of the waterdrip of craven but gravid disingenuous flickers of lambent cloaks of perfidy—that earned its birthright by meditative fruition rather than prodigal tallespin of indolent frapplanks of a vicarious personage rather than an autotelic haecceity showcases the folly of heterodyne inclinations meeting an impasse of accidental dislodgement. The interregnum between the spurts and sprees of luxuriance is a staid pause between continuities of afforded parlance becoming stapled demographic solidarity affixed to a strident gallop of effortful pushes against the tenacity of the slumberous wicked hibernation of vetust magpiety without hieratical internment because youthful industry beats hackneyed bludgeons of wiseacres of a stilted manufacture of steamy nostalgia for lickerish moments that dignify but undermine moral virtues but splash anointed and sometimes disjointed favor upon the congeners to a rabid escapade of a heedless love frowning on the girdles of the prim balderdash of heralded jolts dim on levity and puffed with elusive contextualized control of libidinous serrated defilement because the crotaline **** outmantles the sweedled limber of exploitable folly. The cosseted reality of wheedled gourmands of continuous perception rather than the Gaussian blur of the protean invention of stitches in time that obscure rather than magnify the supernal levity inherent to most artistry is a linchpin of lenient gravitas that levies the lavaderos of ripe perception into annealment.
Excuse the bravado of the gait of winnowed forks in a bronteum for heralds of megaloscopy fastened to the macroscian reality of indelible filigrees of countermanded controversy becoming its best behest in the sempiternal flowering of burgeoned demonstration rather than illustrious overhang of drab slabs of manufacture rather than organism that should be interposed between the constellated concepts of both apperception and the aggrieved counselors to obtuse obsessions that are an improper tutelary for a designated reprisal of the once profane now immediately gratified by ramshackle tenets of a guarded sublimation of the tenets of post-modernism into a sustained force of the internalized tabernacle of haecceity shepherded into exuberance by the manumission of spirit from the ******* of purblind scalds of defamation that incurs the penalty of flippant privation. The refuge the Lord provides is not contingent upon the vagaries of deliberation nor the calculus of oversight but the remontant amaranthine glower of a listed deed becoming an eternal reminder that a dismantled and disjointed world fathoming only remorse rather than the trudge of gentility against the headwinds of brunt asperity will always flout the successor rather than atone for the failure of the imponent condition that constellates around rudimentary drivel grubbing the momentary out of avarice for allotted merchandise rather than glommed magnets to amoeba sentiments for the kisswonk of ulterior motive beyond dungeons of desperation that lurk ghoulishly with spectral frights at the disfigurement of morale created by errors askew rather than a contagion of righteous valor.

   Ask the heedful servant if the captaincy of reneged commitment owes homage to dutiful instruction or whether it is a balking corpse of necrosis accorded to the omphalism of brutish carnal repose in times of sedentary silt siphoned in spelunked rijuice for preordination is a predominant specter for a world scared scurrilous and skittish in a diatribe against the very notion of tribal screeds embedded in the sedimentary heft of traditionalism above the pother of vacillation commended to the apikoros but counterfeit fiat system of a ruddy governance without a supreme magistrate. Now lets venture into the territory of visagists as we envision the swanky subversion of impoverished and nebbich visions of oligochrome that fixates on belabored but dead notions of rigid propriety and levitate above those concerns with a querulous transcendence that never wernaggles about the profaned irrelevance of burlesque tropes of sidereal friction but instead memorializes the thermolysis of permeable endeavor above staid countenances of imposture that lurk in the shadowy penumbra of the connivance of persona above the archetype of the tutelary guardian spirit that through windlass and sometimes deliberation affixes nobility to even the pedestrian in order to assize its proper proportions to granular ironies expounded into megalography transformative by the very rivets of its supersensible existence and cohabitation with histrinkage among human taboos.

   The handiwork of a permeable race prone to exacerbated proclamations of prerogatives bulldozed by the rapid percolation of insoluble quandaries to the gripes of the feast of foofaraw sometimes shelters our otherwise regnant concern about the plenipotentiary God that observes all latent affairs without the paramours that conflate vivid carnality with appeased luxury and superimposes a crafty system of seismic shifts in rantipole dances with numinous flux rather than dissipated militant suppression of the fracklings of dissolute pollution which swirk in their dastardly desperado endeavors to corral the entire monoliths that guard each province into a winnowed rumble of rubble by tarnish of Tyre rather than by the upstart rejoinders of Canaan. Every creature which has the capacity to perceive language is afforded benedictions by the overhailing force of the hypaethral heights of superlative ingenuity founded in the bolted speculation of the endearment of all to tropological seesaws embattled against the hearsay of nyejays that contaminates the telmatology of the ecosystem of revivalism rather than buries the leaden debts of the disjointed revenants of past prominence into recycled irrelevance for posterity rather than for anything but a machination of a clockwork apple rigged for a rotten worm to swindle the sweet delicate tempests of unforeseen disaster to perjuries against financial solidarity.

The spinsters of sardonic drollery underscore the imminence of an incondite cutthroat collapse blackguarded by the hucksters of incontinence grubbing every fetched noisome notion and congealing a bonnyclabber of desiccated mildew that proves vestigial when the victors of time earn their joyous serenade to the pinnacle of the totem of jaundice slits in wavy endeavors for the participles of sejungible syntax of the ephorized furor to outlast the draksteng of droned dereliction manned by half-baked spies of ulterior recitals for imprinted vicissitude in supremacy in synquest for frizzlounges rather than the pedestrian circulatory system of careworn polity. We vaporize the petty hatred of sympatric regelation that neuters the virulence of motivated impediments to the draconian surge of asperity that sinks temporal haplessness as a regaled blasphemy that crowns only the ringed betrothal to spumid serrated halts in slick superstition that is a buggery to the idea of insectivores devouring the erratic chantage of germane germs that pauperize rather than even blind the deafened to be a crutch to vehicular homicide. Melismatic sennet is a dirigible of immense herculean sinew without the traces of vestibulary retches of kisswonked grisly tepid intimidations of eccedentesiasts by the radioglare of wizened corrugations in thanatism that exhort the avatars of narquiddity over the natural departure of revenant souls back to their temporary hostility to crass lifeless decarnate immediacy that slinks with foibles magnified by vertiginous heights of scollardical reputes rigged by the rijuice of the plackiques of meaningless spoils for swashbuckler bonanza borrowed from serrated vengeance exacted in prominence to provide false avenues of extenuation to malefaction that is confidant to the panopticon of exemplary dimples meager in the largesse of the composite realism of a sizable imprint on megalography that outlasts impertinent excuses for dangerous trout swimming against the mobilized selachostomous frizz of sharks gathering to avenge disclosure with insolence and gravid atrocity of incisive surgical evisceration of attempted depositions that falter by innumerable facets of countenance that belie ultimate realism and the perdurable construction of a sturdy hive of bibliognost revelry.

     Even with the blaring sennet of majesty inundating my piecemeal perception with the marstions of flarium that is an efficacy in a flaccid world of otiose pretenses limpid only in folly but contraplex in ironic skewbald skerries of grubbed destination that is the terminus of karezza despite the maledictions of vehement guarded betrayals that conjure up lurid noisome virility against the gamines and gallywows that populate interstellar fictions of virtu rather than mundane pragmatica that astound with the resselenque of contaminated skeumorphs of latent fracture belonging to a skeletonized ossified reification of farce above historicity in seemly seamless countenance with overwrought princely stature deserving integrity to ripples through sparkling opalescence. The vapid insularity of the self-contained mythos of appeased groundlings is based on the rhizic and rhizogenic fracklings destitute in predicative flares to swelter above stratospheres of the illimitable into the dwelling of the highest serenity inherent to the pacification of truth to neglect its egregious errors of mistetches of a ripened pachyderm of bravery in times of austerity and now a reclaimed notion of sempiternal charades swimming above the punitive draksteng of dranger that is enlarged by acclimated attempts at foiled raltention hikkling against its own superior forces of galvanized preterition to elide over screwball insanity of derangement in this virtual paradise of inhabited souls belonging to former times congregating on the pasture of the evanescence of now for all eternity having the optative condition of incarnation above the ferules of the stagnant brevity of oversight in heavenly realms by postulate but not confirmed by regal logic.

     The troponder of the flickered lambent niceties of polity is a countenance that piggybacks on simpered jostles of negligent engrenage to appease sworn enmities among beatific havens for certitude swarmed by the fisticuffs of darbied bridewells of desiccated drainage traversing the distant disdain for the gravel of cemented slits of stilted pragmatica that is a gavel of atrocious estoppel mediated by heroic heresiarchs against pitiable betrayal for forceful remedies in acclimated servitude to the groans and groaks of a life of remorse and dearth rather than the glut of luxuriance in forbearance to its own intorted mirrored ironies that etch infinity with every scrawled rejoinder to austere ploys of checkered rumbles of threat and exigency posed by the clairvoyant hypocrites who benefit greatly by the design of the omphalism above the frays and brays of corporate dogmatism slowly outmoded by vibrant plumages of heteronormative originality beyond petty chantage. A hesitation overcomes the bluster of bravado as the restive earnest concerns of tribulation beset the minauderies of divine affection to reaffirm the teachings of the Gospel so that future generations genuflect beneath the altar of the ultimate stroke of sociogenesis and the blood ransom of suffering that promoted the human latitude and liberty against incarcerated throngs of virtue over caesaraproprism accorded to genuflection beneath denarii rather than absolution by tether to the eternal vine of sensation of the supersensible entelechy of all valiant insurrections against defective polities and renewed policies.

     We thus seek a transdimensional bridge between the morphean virtu of rudimentary alchemy of propitiation divulged by leverage and the teeming rambunctiousness of fiduciary tribes to the ultimate duty of man to consummate the future of eternity even in slowpoke mannerisms that sidle through rigors of entelechy and assize the masterwork of tutelage above the circumforaneous entrenchment of glut above the mastery of the subtle subaudition that beleaguers an adept conflagration of harnessed human ignorance staid in the incarceration of exotic virtues of freewheeling sapience never vulnerary to hospitable concerns that entrenches the verisimilitude of a refracted justice to reign over the stultification of a primitivism inherent to man and not man alone.

‘…. and now, here’s Rick with the latest Market news…’

‘Val, trading was very brisk today, with a number of influences
that set the market off to some defined trends and statements.
Of course, the Human Virtue Exchange always seems to rely
on the volatility that resides ‘between the ears’ as noted
by the veteran brokers on the floor, but the sharp ranges
of prices offered versus profit taking has set the bar
very high in the relative value of Basic Human Virtue.

Now to the numbers: Courage [WHOME], Patience [PP],
and former market darling Perseverance [GULP],
all varied widely today on news from Washington that
their value was doomed to fall in the light of the expected growth
of Persistence [IAM] which history has shown to be a marked drag
on just about everything. Outside of the self –efficacy bazaar,
old standbys  Ambition [HVY], Curiosity [WDF], Industry [HAHA] and Temperance [BFD],
continued their free fall into uncharted areas of cost and return.
Some analysts feel these virtues could be a real bargain in the future
despite their history of poor performance. Could a comeback not seen
since collapse of the Protestant Hypocrisy Era  be in the works? We’ll see as the lack of movement in the Kindness-Generosity-Forgiveness-Compassion Index [FARAWAY]  
leads many to believe that the end of Politeness [UPYRS],
Un-pretentiousness [ME-ME], Self Control [NWAY] and Sportsmanship [LONGONE], may lead to a complete miss-understanding between casual market players and devotees to the cause. The ratios cannot lie.
But without a doubt, today’s big winner was  Self Respect [YUP]
which jumped and amazing 40 points before active trading ceased at the bell. So people feel real good about themselves for reasons
that cannot be explained by the Ego File Indicator alone; this causes this reporter to predict that Naval Gazing [MOM] remains a ‘Hot to Trot’ stock fund
and the Vanity market is always a good bet.
Now, here’s Carl with
today’s Human Emotion Exchange report……’

Whats it be to be handsome?
To have the attention of girls
and then some?
How do I measure self efficacy
when getting a smile
is still a victory?
Should I spend my money
on personal things
or have my wardrobe
bursting at the seams?
Whats the difference between
a lustful stare
and a rejectful laser beam?
Every girl can be hard to get
on welfare
"But there's still someone
for you out there"
Who can see beyond
the mirage at sea
to the core of personality.

While they noticed the stretch of kohl in her eyes,
I could see a pacific of emotions trapped.
While they admired her blushing cheeks,
I could read the paleness she painted red.
While they were going gaga over her smirk,
I could fathom the depth of pain that debarred a hearty gale.
While they were lured by the cascade of her hair when she unscrewed the bun,
I could feel the onus of the tantrums she wanted to turf out.
While they were hypnotized by her mesmeric curves,
I was stunned by the withstanding efficacy of such a fragile body.
While they adored her attire and scarves,
I could trace the bruises she carried with poise.
While they were hung up by the glory of her face,
I could do no help but ride out at the scars she concealed with sprightliness which was the most beautiful thing my eyes could ever have a view of and it left me dazed...
And my mouth wide opened.
-Aparajita Tripathi

Title.        Never take for granted
the greatest power, the power to choose.
                ( An Acrostic ) of 50 lines.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Never take for granted the greatest power.
             The power to choose !
Every concession,or subsidy in whatever form
       As a contribution or donation to charity
Value this as a highest prize , volition is the          
   Sacred power to choose ,use that power well
Efficacy empowering the production of results
   By marching forward in a positive direction
Ranges of choices sometimes oh so wide as to
   Make a decision very difficult indeed.

Two equally ,typically undesirable alternatives
     We get to know typically as a dilemma
An act of choosing to take up one option as
     Opposed to another to maintain momentum
Knowing that there’s no apparent option rather
   than the real , you have “Hobson’s choice”
Embarras de richesses you become spoilt for
     Choice, is the other side of the coin.

From the comparison betwixt the humble poet
      And the power hungry “Megalomaniac,
Optimising in an act of choosing between the
  two, voluntary ,of one’s own free will Choose
Rights to act or judge by your power of choice
   you may call this discretion,one or t’other

God grants such power as yet unmaterialised
    and unrealised which he labels potential.
Relinquish that potential at your peril
   you may never live to see that choice again
An area of power and influence you may get
    to understand as your domain but reflect
Never take for granted the greatest power,
   the power to choose.
Twitter and chat with all and sundry
    relatives you’re born to, friends you choose
Even if you use your power of wit n influence
   and see it as weight n clout you throw about
Delegate or depute and assign somebody to
    make your choices for you. No don’t quit !

The A to Z of choices takes no time to ponder
    If you take for granted the power to choose
Hub of influence power centre ganglion from
    which nerve fibres radiate to every solution
Even by commencing from “A”. Aha . Eureka!
   you have chosen first time lucky .But wait. !

Great though he may appear as the “Boy”
  of your dreams, will he stand the test of time?
Retiring back into your shell ,your”Colleagues“
  At work never choose to know the real you.
Every “Demi-God “or “Elder”that you meet ,
  give respect to ,spoil it all by choosing not to.
An “F” word muttered under your breath .
    A “Gender” question,which choice of path?
To “Hero-worship” then a real life commitment
      “Interpreters “ of choices thru a Drago Man
Established in the art of choice as lead by
  “Jesus” Christ “Knowledge “that it will not fail

Superimposed, will “Liquidise “and blend
    all the choices that are available “Mmmmm”
To the most “Natural “smoothie that you have
   ever chosen to drink. “Ohhhh” yes. !  

Pause and “ Pause” again ,do we really under
    stand the power of choice. Procrastinate  !
Oh put off until tomorrow, “Quit” whilst ahead
      “Realise” your winnings in the now.
Weather you “Seek” perfection ,or an easy
    way out . “ Take” heart it is your choice
Ethereal choice becomes the mother of
    invention, when and where necessities dwell
React with an un-earthly prowess and ability
   to establish what was to be the right choice.

The “ Virtual “ choice that you could have
   made under the circumstances, bono-fide.
Having and knowing you have the power
    Of choice, it leaves it in your hands.
Even if you get the choice “Wrong” this time
    it is your mistake , no one else’s

Pretty soon you will know the error and mark
  It with an “X” n strive to get it right next time
Only “You “ have this individual power
   To make up your own mind .You do, don’t you
We can all be as”Zealous “and pedantic as
   You like in life but choices win through .
Even if you can’t be bothered to take the
   Choice to read this poem, on and on and on.
Reacting in a moment of impatience.
  “ what am I doing wasting time reading this?”

To have a power of choice is a valuable power
    not granted to all people of the world.
Oh stay with me ! Tell me that you understand
    the meaning of this poem. Do I make it clear

Can you choose? Do you choose? Are you
   exercising a sacred power that you’re given?
Holy power, not given to timid mice sitting
  on the fence waiting for the right choice
Oh no ! Never take for granted the greatest
    power, the power to choose.
Onlookers and bystanders are you learning
   from any of the simple examples I have set?
See unless you see and understand the good
   and bad choices made by man thru ages .
Earth and the Universe would have failed
  In its quest to provide a Heaven that we seek
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Written by Philip. 30/10/2018.

HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to us e
M-M-R II safely and effectively. See full prescribing information
for M-M-R II.
M-M-R® II (Measles, Mumps, and Rubella Virus Vaccine Live)
Suspension for subcutaneous injection
Initial U.S. Approv al: 1978
-------------------------------INDICATIONS AND USAGE-------------------------------
M-M-R II is a vaccine indicated for active immunization for the
prevention of measles, mumps, and rubella in individuals 12 months of
age and older. (1)
-------------------------- DOSAGE AND ADMINISTRATION--------------------------
Administer a 0.5-mL dose of M-M-R II subcutaneously. (2.1)
• The first dose is administered at 12 to 15 months of age. (2.1)
• The second dose is administered at 4 to 6 years of age. (2.1)
------------------------DOSAGE FORMS AND STRENGTHS -----------------------
Suspension for injection (0.5-mL dose) supplied as a lyophilized
vaccine to be reconstituted using accompanying sterile diluent. (3)
---------------------------------- CONTRAINDICATIONS ----------------------------------
• Hypersensitivity to any componentof the vaccine. (4.1)
• Immunosuppression. (4.2)
• Moderate or severe febrile illness. (4.3)
• Active untreated tuberculosis. (4.4)
• Pregnancy. (4.5, 8.1)
-------------------------- WARNINGS AND PRECAUTIONS --------------------------
• Use caution when administering M-M-R II to individuals with a
history of febrile seizures. (5.1)
• Use caution when administering M-M-R II to individuals with
anaphylaxis or immediate hypersensitivity following egg ingestion.
(5.2)
• Use caution when administering M-M-R II to individuals with a
history of thrombocytopenia. (5.3)
• Immune Globulins (IG) and other blood products should not be
given concurrently with M-M-R II. (5.4, 7.2)
----------------------------------ADVERSE REACTIONS----------------------------------
See full prescribing information for adverse reactions occurring duri ng
clinical trialsor the post-marketing period. (6)
To report SUSPECTED ADVERSE REACTIONS, contact Merck
Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., at 1-8 7 7 -
888-4231 or VAERS at 1-800-822-7967 or www.vaers.hhs.gov.
-----------------------------------DRUG INTERACTIONS----------------------------------
• Administration of immune globulins and other blood products
concurrently with M-M-R II vaccine may interfere with the
expected immune response. (7.2)
• M-M-R II vaccination may result in a temporary depression of
purified protein derivative (PPD) tuberculin skin sensitivity. (7.3)
-------------------------- USE IN SPECIFIC POPULATIONS--------------------------
• Pregnancy: Do not administer M-M-R II to females who are
pregnant. Pregnancy should be avoided for 1 month following
vaccination with M-M-R II. (4.5, 8.1, 17)
See 17 for PATIENT COUNSELING INFORMATION and FDA
approv ed patient labeling.
Rev ised: 06/2020
FULL PRESCRIBING INFORMATION: CONTENTS
1 INDICATIONS AND USAGE
2 DOSAGE AND ADMINISTRATION
2.1 Dose and Schedule
2.2 Preparation andAdministration
3 DOSAGE FORMS AND STRENGTHS
4 CONTRAINDICATIONS
4.1 Hypersensitivity
4.2 Immunosuppression
4.3 Moderate or Severe Febrile Illness
4.4 Active Untreated Tuberculosis
4.5 Pregnancy
5 WARNINGS AND PRECAUTIONS
5.1 Febrile Seizure
5.2 Hypersensitivity to Eggs
5.3 Thrombocytopenia
5.4 Immune Globulins and Transfusions
6 ADVERSE REACTIONS
7 DRUG INTERACTIONS
7.1 Corticosteroids and Immunosuppressive Drugs
7.2 Immune Globulinsand Transfusions
7.3 Tuberculin Skin Testing
7.4 Use with Other Live Viral Vaccines
8 USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
8.2 Lactation
8.4 Pediatric Use
8.5 Geriatric Use
11 DESCRIPTION
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
12.6 Persistence of Antibody Responses After Vaccination
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
14 CLINICAL STUDIES
14.1 Clinical Efficacy
14.2 Immunogenicity
15 REFERENCES
16 HOW SUPPLIED/STORAGE AND HANDLING
17 PATIENT COUNSELING INFORMATION
Sections or subsections omitted from the full prescribing info rma tion
are not listed.
2
FULL PRESCRIBING INFORMATION
1 INDICATIONS AND USAGE
M-M-R® II is a vaccine indicated for active immunization for the prevention of measles, mumps, and
rubella in individuals 12 months of age and older.
2 DOSAGE AND ADMINISTRATION
For subcutaneous use only.
2.1 Dose and Schedule
Each 0.5 mL dose is administered subcutaneously.
The first dose is administered at 12 to 15 months of age. A second dose is administered at 4 to 6
years of age.
The second dose may be administered prior to 4 years of age, provided that there is a minimum
interval of one month between the doses of measles, mumps and rubella virus vaccine, live {1-2}.
Children who received an initial dose of measles, mumps and rubella vaccine prior to their first
birthday should receive additional doses of vaccine at 12-15 months of age and at 4-6 years of age to
complete the vaccination series [see Clinical Studies (14.2)].
For post-exposure prophylaxis for measles, administer a dose of M-M-R II vaccine within 72 hours
after exposure.
2.2 Preparation and Administration
Use a sterile syringe free of preservatives, antiseptics, and detergents for each injection and/or
reconstitution of the vaccine because these substances may inactivate the live virus vaccine. To
reconstitute, use only the diluent supplied with the vaccine since it is free of preservatives or other
antiviral substances which might inactivate the vaccine.
Withdraw the entire volume of the supplied diluent from its vial and inject into lyophilized vaccine vial.
Agitate to dissolve completely. Discard if the lyophilized vaccine cannot be dissolved.
Withdraw the entire volume of the reconstituted vaccine and inject subcutaneously into the outer
aspect of the upper arm (deltoid region) or into the higher anterolateral area of the thigh.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to
administration, whenever solution and container permit. Visually inspect the vaccine before and after
reconstitution prior to administration. Before reconstitution, the lyophilized vaccine is a light yellow
compact crystalline plug, when reconstituted, is a clear yellow liquid. Discard if particulate matter or
discoloration are observed in the reconstituted vaccine.
To minimize loss of potency, administer M-M-R II as soon as possible after reconstitution. If not used
immediately, the reconstituted vaccine may be stored between 36°F to 46°F (2°C to 8°C), protected from
light, for up to 8 hours. Discard reconstituted vaccine if it is not used within 8 hours.
3 DOSAGE FORMS AND STRENGTHS
M-M-R II vaccine is a suspension for injection supplied as a single dose vial of lyophilized vaccine to
be reconstituted using the accompanying sterile diluent [see Dosage and Administration (2.2) and How
Supplied/Storage and Handling (16)]. A single dose after reconstitution is 0.5 mL.
4 CONTRAINDICATIONS
4.1 Hypersensitivity
Do not administer M-M-R II vaccine to individuals with a history of hypersensitivity to any component
of the vaccine (including gelatin) {3} or who have experienced a hypersensitivity reaction following
administration of a previous dose of M-M-R II vaccine or any other measles, mumps and rubellacontaining vaccine. Do not administer M-M-R II vaccine to individuals with a history of anaphylaxis to
neomycin [see Description (11)].
4.2 Immunosuppression
Do not administer M-M-R II vaccine to individuals who are immunodeficient or immunosuppressed due
to disease or medical therapy. Measles inclusion body encephalitis {4} (MIBE), pneumonitis {5} and death
as a direct consequence of disseminated measles vaccine virus infection have been reported in
3
immunocompromised individuals inadvertently vaccinated with measles-containing vaccine. In this
population, disseminated mumps and rubella vaccine virus infection have also been reported.
Do not administer M-M-R II to individuals with a family history of congenital or hereditary
immunodeficiency, until the immune competence of the potential vaccine recipient is demonstrated.
4.3 Moderate or Severe Febrile Illness
Do not administer M-M-R II vaccine to individuals with an active febrile illness with fever >101.3F
(>38.5C).
4.4 Active Untreated Tuberculosis
Do not administer M-M-R II vaccine to individuals with active untreated tuberculosis (TB).
4.5 Pregnancy
Do not administer M-M-R II to individuals who are pregnant or who are planning on becoming
pregnant within the next month [see Use in Specific Populations (8.1) and Patient Counseling Information
(17)].
5 WARNINGS AND PRECAUTIONS
5.1 Febrile Seizure
There is a risk of fever and associated febrile seizure in the first 2 weeks following immunization with
M-M-R II vaccine. For children who have experienced a previous febrile seizure (from any cause) and
those with a family history of febrile seizures there is a small increase in risk of febrile seizure following
receipt of M-M-R II vaccine [see Adverse Reactions (6)].
5.2 Hypersensitivity to Eggs
Individuals with a history of anaphylactic, anaphylactoid, or other immediate reactions (e.g., hives,
swelling of the mouth and throat, difficulty breathing, hypotension, or shock) subsequent to egg ingestion
may be at an enhanced risk of immediate-type hypersensitivity reactions after receiving M-M-R II vaccine
.The potential risks and known benefits should be evaluated before considering vaccination in these
individuals.
5.3 Thrombocytopenia
Transient thrombocytopenia has been reported within 4-6 weeks following vaccination with measles,
mumps and rubella vaccine. Carefully evaluate the potential risk and benefit of vaccination in children
with thrombocytopenia or in those who experienced thrombocytopenia after vaccination with a previous
dose of measles, mumps, and rubella vaccine {6-8} [see Adverse Reactions (6)].
5.4 Immune Globulins and Transfusions
Immune Globulins (IG) and other blood products should not be given concurrently with M-M-R II [see
Drug Interactions (7.2)]. These products may contain antibodies that interfere with vaccine virus
replication and decrease the expected immune response.
The ACIP has specific recommendations for intervals between administration of antibody containing
products and live virus vaccines.
6 ADVERSE REACTIONS
The following adverse reactions include those identified during clinical trials or reported during postapproval use of M-M-R II vaccine or its individual components.
Body as a Whole
Panniculitis; atypical measles; fever; syncope; headache; dizziness; malaise; irritability.
Cardiovascular System
Vasculitis.
Digestive System
Pancreatitis; diarrhea; vomiting; parotitis; nausea.
Hematologic and Lymphatic Systems
Thrombocytopenia; purpura; regional lymphadenopathy; leukocytosis.
Immune System
Anaphylaxis, anaphylactoid reactions, angioedema (including peripheral or ****** edema) and
bronchial spasm.
Musculoskeletal System
Arthritis; arthralgia; myalgia.
4
Nervous System
Encephalitis; encephalopathy; measles inclusion body encephalitis (MIBE) subacute sclerosing
panencephalitis (SSPE); Guillain-Barré Syndrome (GBS); acute disseminated encephalomyelitis (ADEM);
transverse myelitis; febrile convulsions; afebrile convulsions or seizures; ataxia; polyneuritis;
polyneuropathy; ocular palsies; paresthesia.
Respiratory System
Pneumonia; pneumonitis; sore throat; cough; rhinitis.
Skin
Stevens-Johnson syndrome; acute hemorrhagic edema of infancy; Henoch-Schönlein purpura;
erythema multiforme; urticaria; rash; measles-like rash; pruritus; injection site reactions (pain, erythema,
swelling and vesiculation).
Special Senses — Ear
Nerve deafness; otitis media.
Special Senses — Eye
Retinitis; optic neuritis; papillitis; conjunctivitis.
Urogenital System
Epididymitis; orchitis.
7 DRUG INTERACTIONS
7.1 Corticosteroids and Immunosuppressive Drugs
M-M-R II vaccine should not be administered to individuals receiving immunosuppressive therapy,
including high dose corticosteroids. Vaccination with M-M-R II vaccine can result in disseminated disease
due to measles vaccine in individuals on immunosuppressive drugs [see Contraindications (4.2)].
7.2 Immune Globulinsand Transfusions
Administration of immune globulins and other blood products concurrently with M-M-R II vaccine may
interfere with the expected immune response {9-11} [see Warnings and Precautions (5.4)]. The ACIP has
specific recommendations for intervals between administration of antibody containing products and live
virus vaccines.
7.3 Tuberculin Skin Testing
It has been reported that live attenuated measles, mumps and rubella virus vaccines given individually
may result in a temporary depression of tuberculin skin sensitivity. Therefore, if a tuberculin skin test with
tuberculin purified protein derivative (PPD) is to be done, it should be administered before, simultaneously
with, or at least 4 to 6 weeks after vaccination with M-M-R II vaccine.
7.4 Use with Other Live Viral Vaccines
M-M-R II vaccine can be administered concurrently with other live viral vaccines. If not given
concurrently, M-M-R II vaccine should be given one month before or one month after administration of
other live viral vaccines to avoid potential for immune interference.
8 USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
Risk Summary
M-M-R II vaccine is contraindicated for use in pregnant women because infection during pregnancy
with the wild-type viruses has been associated with maternal and fetal adverse outcomes.
Increased rates of spontaneous abortion, stillbirth, premature delivery and congenital defects have
been observed following infection with wild-type measles during pregnancy. {12,13} Wild-type mumps
infection during the first trimester of pregnancy may increase the rate of spontaneous abortion.
Infection with wild-type rubella during pregnancy can lead to miscarriage or stillbirth. If rubella infection
occurs during the first trimester of pregnancy, it can result in severe congenital defects, Congenital
Rubella Syndrome (CRS). Congenital rubella syndrome in the infant includes but is not limited to eye
manifestations (cataracts, glaucoma, retinitis), congenital heart defects, hearing loss, microcephaly, and
intellectual disabilities. M-M-R II vaccine contains live attenuated measles, mumps and rubella viruses. It
is not known whether M-M-R II vaccine can cause fetal harm when administered to pregnant woman.
There are no adequate and well-controlled studies of M-M-R II vaccine administration to pregnant
women.
5
All pregnancies have a risk of birth defect, loss or other adverse outcomes. In the US general
population, the estimated background risk of major birth defects and miscarriage in clinically recognized
pregnancies is 2% to 4% and 15% to 20%, respectively.
Available data suggest the rates of major birth defects and miscarriage in women who received
M-M-R II vaccine within 30 days prior to pregnancy or during pregnancy are consistent with estimated
background rates (see Data).
Data
Human Data
A cumulative assessment of post-marketing reports for M-M-R II vaccine from licensure 01 April 1978
through 31 December 2018, identified 796 reports of inadvertent administration of M-M-R II vaccine
occurring 30 days before or at any time during pregnancy with known pregnancy outcomes. Of the
prospectively followed pregnancies for whom the timing of M-M-R II vaccination was known, 425 women
received M-M-R II vaccine during the 30 days prior to conception through the second trimester. The
outcomes for these 425 prospectively followed pregnancies included 16 infants with major birth defects, 4
cases of fetal death and 50 cases of miscarriage. No abnormalities compatible with congenital rubella
syndrome have been identified in patients who received M-M-R II vaccine. Rubella vaccine viruses can
cross the placenta, leading to asymptomatic infection of the fetus. Mumps vaccine virus has also been
shown to infect the placenta {14}, but there is no evidence that it causes congenital malformations or
disease in the fetus or infant .
The CDC established the Vaccine in Pregnancy registry (1971-1989) of women who had received
rubella vaccines within 3 months before or after conception. Data on 1221 inadvertently vaccinated
pregnant women demonstrated no evidence of an increase in fetal abnormalities or cases of Congenital
Rubella Syndrome (CRS) in the enrolled women {15}.
8.2 Lactation
Risk Summary
It is not known whether measles or mumps vaccine virus is secreted in human milk. Studies have
shown that lactatingpostpartum women vaccinated with live attenuated rubella vaccine may secrete the
virus in breast milk and transmit it to breast-fed infants.{16,17} In the breast-fed infants with serological
evidence of rubella virus vaccine strain antibodies, none exhibited severe disease; however, one
exhibited mild clinical illness typical of acquired rubella.{18,19}
The developmental and health benefits of breastfeeding should be considered along with the mother’s
clinical need for M-M-R II, and any potential adverse effects on the breastfed child from M-M-R II or from
the underlying maternal condition. For preventive vaccines, the underlying maternal condition is
susceptibility to disease prevented by the vaccine.
8.4 Pediatric Use
M-M-R II vaccine is not approved for individuals less than 12 months of age. Safety and effectiveness
of measles vaccine in infants below the age of 6 months have not been established [see Clinical Studies
(14)]. Safety and effectiveness of mumps and rubella vaccine in infants less than 12 months of age have
not been established.
8.5 Geriatric Use
Clinical studies of M-M-R II did not include sufficient numbers of seronegative subjects aged 65 and
over to determine whether they respond differently from younger subjects.
11 Description
M-M-R II vaccine is a sterile lyophilized preparation of (1) Measles Virus Vaccine Live, an attenuated
line of measles virus, derived from Enders' attenuated Edmonston strain and propagated in chick embryo
cell culture; (2) Mumps Virus Vaccine Live, the Jeryl Lynn™ (B level) strain of mumps virus propagated in
chick embryo cell culture; and (3) Rubella Virus Vaccine Live, the Wistar RA 27/3 strain of live attenuated
rubella virus propagated in WI-38 human diploid lung fibroblasts. {20,21} The cells, virus pools,
recombinant human serum albumin and fetal bovine serum used in manufacturing are tested and
determined to be free of adventitious agents.
After reconstitution, each 0.5 mL dose contains not less than 3.0 log10 TCID50 (tissue culture infectious
doses) of measles virus; 4.1 log10 TCID50 of mumps virus; and 3.0 log10 TCID50 of rubella virus.
Each dose is calculated to contain sorbitol (14.5 mg), sucrose(1.9 mg), hydrolyzed gelatin (14.5 mg),
recombinant human albumin (≤0.3 mg), fetal bovine serum (<1 ppm), approximately 25 mcg of neomycin
and other buffer and media ingredients. The product contains no preservative.
6
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
M-M-R II vaccination induces antibodies to measles, mumps, and rubella associated with protection
which can be measured by neutralization assays, hemagglutination-inhibition (HI) assays, or enzyme
linked immunosorbent assay (ELISA) tests. Results from efficacy studies or effectivenes s studies that
were previously conducted for the component vaccines of M-M-R II were used to define levels of serum
antibodies that correlated with protection against measles, mumps, and rubella [see Clinical Studies (14)].
12.6 Persistence of Antibody Responses After Vaccination
Neutralizing and ELISA antibodies to measles, mumps, and rubella viruses are still detectable in 95-
100%, 74-91%, and 90-100% of individuals respectively, 11 to 13 years after primary vaccination. {22-28}
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
M-M-R II vaccine has not been evaluated for carcinogenic or mutagenic potential or impairment of
fertility.
14 CLINICAL STUDIES
14.1 Clinical Efficacy
Efficacy of measles, mumps, and rubella vaccines was established in a series of double-blind
controlled trials. {29-34} These studies also established that seroconversion in response to vaccination
against measles, mumps and rubella paralleled protection. {35-38}
14.2 Immunogenicity
Clinical studies enrolling 284 triple seronegative children, 11 months to 7 years of age, demonstrated
that M-M-R II vaccine is immunogenic. In these studies, a single injection of the vaccine induced measles
HI antibodies in 95%, mumps neutralizing antibodies in 96%, and rubella HI antibodies in 99% of
susceptible individuals.
A study of 6-month-old and 15-month-old infants born to mothers vaccinated with a measles vaccine in
childhood, demonstrated that, following infant and toddler vaccination with Measles Virus Vaccine, Live
(previously US-licensed, manufactured by Merck), 74% of the 6-month-old infants developed detectable
neutralizing antibody titers while 100% of the 15-month-old infants vaccinated with Measles Virus
Vaccine, Live or M-M-R II vaccine developed neutralizing antibodies {39}. When the 6-month-old infants
of immunized mothers were revaccinated at 15 months with M-M-R II vaccine, they developed antibody
titers similar to those of toddlers who were vaccinated previously at 15-months of age.
15 REFERENCES
1. General Recommendations on Immunization, Recommendations of the Advisory Committee on Immunization Practices, MMWR
43(RR-1): 1-38, January 28, 1994.
2. Measles, Mumps, and Rubella — Vaccine Use and Strategies for Elimination of Measles, Rubella, a n d Co n g e nita l Ru b e lla
Syndrome and Control of Mumps: Recommendations of the Advisory Committee on Immunization Practice s (ACIP), M M WR
47(RR-8): May 22, 1998.
3. Kelso, J.M.; Jones, R.T.; Yunginger, J.W.: Anaphylaxis to measles, mumps, and rubella vaccine mediated by IgE to gel atin , J.
Allergy Clin. Immunol. 91: 867-872, 1993.
4. Bitnum, A.; et al: Measles Inclusion Body Encephalitis Caused by the Vaccine Strain of Measles Virus. Cl i n . In fect. Di s. 2 9 :
855-861, 1999.
5. Angel, J.B.; et al: Vaccine Associated Measles Pneumonitis in an Adult with AIDS. Annals of Internal Medicine, 129: 1 0 4 -1 06 ,
1998.
6. Cecinati V, et al. Vaccine administration and the development of immune thrombocyto pe ni c p urp u ra i n ch i ld re n. Hu m an
Vaccines & Immunotherapeutics 9:5, 2013.
7. Mantadakis E, Farmaki E, Buchanan GR. Thrombocytopenic Purpura after Measles-Mumps-Rubella Vaccination: A Systematic
Review of the Literature and Guidance for Management. J Ped 156(4): 2010.
8. Andrews N, Stowe J, Miller E, Svanstrom H, Johansen K, Bonhoeffer J, et al. A collaborative approach to investigating th e ri sk
of thrombocytopenic purpura after measles-mumps-rubella vaccination in England and Denmark. Vaccine. 2012;30:3042‐6.
9. Rubella Prevention: Recommendation of the Immunization Practices Advisory Committee (ACIP), MM WR 3 9 (RR-1 5 ): 1 -1 8 ,
November 23, 1990.
7
10. Peter, G.; et al (eds): Report of the Committee on Infectious Diseases, Twenty-fourth Edition, American Academy of Pediatri cs,
344-357, 1997.
11. Measles Prevention: Recommendations of the Immunization Practices Advisory Committee (ACIP), MMWR 38(S-9): 5-22,
December 29, 1989.
12. Eberhart-Phillips, J.E.; et al: Measles in pregnancy: a descriptive study of 58 cases. Obstetrics and Gynecology, 82(5): 797-801,
November 1993.
13. Jespersen, C.S.; et al: Measles as a cause of fetal defects: A retrospective study of ten measles epidemics in Greenland. Acta
Paediatr Scand. 66: 367-372, May 1977.
14. Yamauchi T, Wilson C, Geme JW Jr. Transmission of live, attenuated mumps virus to the hu m a n p l ace n ta . N En g l J M e d .
1974;290(13):710‐712.
15. Rubella Vaccination during Pregnancy —United States, 1971-1988. JAMA. 1989;261(23):3374–3383.
16. Losonsky, G.A.; Fishaut, J.M.; Strussenber, J.; Ogra, P.L.: Effect of immunization against rubella on lactation products. II.
Maternal-neonatal interactions, J. Infect. Dis. 145: 661-666,1982.
17. Losonsky, G.A.; Fishaut, J.M.; Strussenber, J.; Ogra, P.L.: Effect of immunization against rubella on lactation products. I.
Development and characterization of specific immunologic reactivity in breast milk, J. Infect. Dis. 145: 654-660, 1982.
18. Landes, R.D.; Bass, J.W.; Millunchick, E.W.; Oetgen, W.J.: Neonatal rubella following postpartum maternal i mm un izatio n , J.
Pediatr. 97: 465-467, 1980.
19. Lerman, S.J.: Neonatal rubella following postpartum maternal immunization, J. Pediatr. 98: 668, 1981. (Letter)
20. Plotkin, S.A.; Cornfeld, D.; Ingalls, T.H.: Studiesof immunization with living rubella virus: Trialsin children with a strain culture d
from an aborted fetus, Am. J. Dis. Child. 110: 381-389, 1965.
21. Plotkin, S.A.; Farquhar, J.; Katz, M.; Ingalls, T.H.: A new attenuated rubella virus grown in human fi bro b la sts: Evi d e n ce fo r
reduced nasopharyngeal excretion, Am. J. Epidemiol. 86: 468-477, 1967.
22. Weibel, R.E.; Carlson, A.J.; Villarejos, V.M.; Buynak, E.B.; McLean, A.A.; Hilleman, M.R.: Clinical and Labo ra tory Stu d ie s o f
Combined Live Measles, Mumps, and Rubella Vaccines Using the RA 27/3 Rubella Virus, Proc. So c. Exp . Bi ol. M e d. 1 6 5 :
323-326, 1980.
23. Watson, J.C.; Pearson, J.S.; Erdman, D.D.; et al: An Evaluation of Measles RevaccinationAmong School-Entry Age Ch i ld re n,
31st Interscience Conference on Antimicrobial Agents and Chemotherapy, Abstract #268, 143, 1991.
24. Unpublished data from the files of Merck Research Laboratories.
25. Davidkin, I.; Jokinen, S.; Broman, M. et al.: Persistence of Measles, Mumps, and Rubella Antibodies in a n M M R -Va ccina ted
Cohort: A 20-Year Follow-up, JID 197:950–6, April 2008.
26. LeBaron, W.; Beeler J.; Sullivan, B.; et al.: Persistence of Measles Antibodies After 2 Doses of Measles Vaccine in a
Postelimination Environment, Arch Pediatr Adolesc Med. 161:294-301, March 2007.
27. LeBaron, C.; Forghani, B.; Beck, C. et al.: Persistence of Mumps Antibodies after 2 Doses of Measles-Mumps-Rubella Vaccine,
JID 199:552– 60 , February 2009.
28. LeBaron, W.; Forghani, B.; Matter, L. et al.: Persistence of Rubella Antibodies after 2 Doses of Measles-Mumps-Rubella
Vaccine, JID 200:888–99, September 2009.
29. Hilleman, M.R.; Buynak, E.B.; Weibel, R.E.; et al: Development and Evaluation of the Moraten MeaslesVirusVa cci n e , JAM A
206(3): 587-590, 1968.
30. Weibel, R.E.; Stokes, J.; Buynak, E.B.; et al: Live, Attenuated Mumps Virus Vaccine 3. Clinical and Serologic Aspects in a Fiel d
Evaluation,N. Engl. J. Med. 276: 245-251, 1967.
31. Hilleman, M.R.; Weibel, R.E.; Buynak, E.B.; et al:Live, Attenuated Mumps VirusVaccine 4. ProtectiveEfficacy as Measure d i n
a Field Evaluation, N. Engl. J. Med. 276: 252-258, 1967.
32. Cutts, F.T.; Henderson, R.H.; Clements, C.J.; et al: Principles of measles control, Bull WHO 69(1): 1-7, 1991.
33. Weibel, R.E.; Buynak, E.B.; Stokes, J.; et al: Evaluation Of Live Attenuated Mumps Virus Vaccine, Strain Jeryl Lynn, First
International Conference on VaccinesAgainst Viral and Rickettsial Diseases of Man, World Health Organization, No. 147, M a y
1967.
34. Leibhaber, H.; Ingalls, T.H.; LeBouvier, G.L.; et al: Vaccination With RA 27/3 Rubella Vaccine, Am. J. Dis. Child. 123: 133-1 3 6,
February 1972.
35. Rosen, L.: Hemagglutination and Hemagglutination-Inhibition with Measles Virus, Virology 13: 139-141, January 1961.
36. Brown, G.C.; et al: Fluorescent-Antibody Marker for Vaccine-Induced Rubella Antibodies, Infection and Immunity 2(4): 360-363,
1970.
8
37. Buynak, E.B.; et al: Live Attenuated Mumps Virus Vaccine 1. Vaccine Development, Proceedings of the Society for
Experimental Biology and Medicine, 123: 768-775, 1966.
38. Hilleman M.R., Studies of Live Attenuated Measles Virus Vaccine in Man: II. Appraisal of Efficacy. Amer. J. o f Pu b l ic He a lth ,
52(2):44-56, 1962.
39. Johnson, C.E.; et al: Measles Vaccine Immunogenicity in 6- Versus 15-Month-Old Infants Born to Mothers in the Measles
Vaccine Era, Pediatrics, 93(6): 939-943, 1994.
16 HOW SUPPLIED/STORAGE AND HANDLING
No. 4681 ⎯ M-M-R II vaccine is supplied as follows:
(1) a box of 10 single-dose vials of lyophilized vaccine (package A), NDC 0006-4681-00
(2) a box of 10 vials of diluent (package B)
Exposure to light may inactivate the vaccine viruses.
Before reconstitution, refrigerate the lyophilized vaccine at 36°F to 46°F, (2°C to 8°C).
Store accompanying diluent in the refrigerator with the lyophilized vaccine or separately at room
temperature (68° to 77°F, 20° to 25°C). Do not freeze the diluent.
Administer M-M-R II vaccine as soon as possible after reconstitution. If not administered immediately,
reconstituted vaccine may be stored between 36°F to 46°F (2°C to 8°C), protected from light, for up to 8
hours. Discard reconstituted vaccine if it is not used within 8 hours.
For information regarding the product or questions regarding storage conditions, call 1-800-
MERCK-90 (1-800-637-2590).
17 PATIENT COUNSELING INFORMATION
Advise the patient to read the FDA-approved patient labeling (Patient Package Insert).
Discuss the following with the patient:
• Provide the required vaccine information to the patient, parent, or guardian.
• Inform the patient, parent, or guardian of the benefits and risks associated with vaccination.
• Question the patient, parent, or guardian about reactions to a previous dose of M-M-R II vaccine
or other measles-, mumps-, or rubella-containing vaccines.
• Question females of reproductive potential regarding the possibility of pregnancy. Inform female
patients to avoid pregnancy for 1 month following vaccination [see Contraindications (4.5) and
Use in Specific Populations (8.1)].
• Inform the patient, parent, or guardian that vaccination with M-M-R II may not offer 100%
protection from measles, mumps, and rubella infection.
• Instruct patients, parents, or guardians to report any adverse reactions to their health-care
provider. The U.S. Department of Health and Human Services has established a Vaccine
Adverse Event Reporting System (VAERS) to accept all reports of suspected adverse events
after the administration of any vaccine, including but not limited to the reporting of events required
by the National Childhood Vaccine Injury Act of 1986. For information or a copy of the vaccine
reporting form, call the VAERS toll-free number at 1-800-822-7967, or report online at
https://www.vaers.hhs.gov.
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ENDNOTES:

(1)  ll. 1-9 are preserved by Diodorus Siculus iii. 66. 3; ll.
     10-21 are extant only in M.
(2)  Dionysus, after his untimely birth from Semele, was sewn
     into the thigh of Zeus.
(3)  sc. Semele.  Zeus is here speaking.
(4)  The reference is apparently to something in the body of the
     hymn, now lost.
(5)  The Greeks feared to name Pluto directly and mentioned him
     by one of many descriptive titles, such as 'Host of Many':
     compare the Christian use of O DIABOLOS or our 'Evil One'.
(6)  Demeter chooses the lowlier seat, supposedly as being more
     suitable to her assumed condition, but really because in her
     sorrow she refuses all comforts.
(7)  An act of communion -- the drinking of the potion here
     described -- was one of the most important pieces of ritual
     in the Eleusinian mysteries, as commemorating the sorrows of
     the goddess.
(8)  Undercutter and Woodcutter are probably popular names (after
     the style of Hesiod's 'Boneless One') for the worm thought
     to be the cause of teething and toothache.
(9)  The list of names is taken -- with five additions -- from
     Hesiod, "Theogony" 349 ff.: for their general significance
     see note on that passage.
(10) Inscriptions show that there was a temple of Apollo
     Delphinius (cp. ii. 495-6) at Cnossus and a Cretan month
     bearing the same name.
(11) sc. that the dolphin was really Apollo.
(12) The epithets are transferred from the god to his altar
     'Overlooking' is especially an epithet of Zeus, as in
     Apollonius Rhodius ii. 1124.
(13) Pliny notices the efficacy of the flesh of a tortoise
     against withcraft.  In "Geoponica" i. 14. 8 the living
     tortoise is prescribed as a charm to preserve vineyards from
     hail.
(14) Hermes makes the cattle walk backwards way, so that they
     seem to be going towards the meadow instead of leaving it
     (cp. l. 345); he himself walks in the normal manner, relying
     on his sandals as a disguise.
(15) Such seems to be the meaning indicated by the context,
     though the verb is taken by Allen and Sikes to mean, 'to be
     like oneself', and so 'to be original'.
(16) Kuhn points out that there is a lacuna here.  In l. 109 the
     borer is described, but the friction of this upon the
     fireblock (to which the phrase 'held firmly' clearly
     belongs) must also have been mentioned.
(17) The cows being on their sides on the ground, Hermes bends
     their heads back towards their flanks and so can reach their
     backbones.
(18) O. Muller thinks the 'hides' were a stalactite formation in
     the 'Cave of Nestor' near Messenian Pylos, -- though the
     cave of Hermes is near the Alpheus (l. 139).  Others suggest
     that actual skins were shown as relics before some cave near
     Triphylian Pylos.
(19) Gemoll explains that Hermes, having offered all the meat as
     sacrifice to the Twelve Gods, remembers that he himself as
     one of them must be content with the savour instead of the
     substance of the sacrifice.  Can it be that by eating he
     would have forfeited the position he claimed as one of the
     Twelve Gods?
(20) Lit. 'thorn-plucker'.
(21) Hermes is ambitious (l. 175), but if he is cast into Hades
     he will have to be content with the leadership of mere
     babies like himself, since those in Hades retain the state
     of growth -- whether childhood or manhood -- in which they
     are at the moment of leaving the upper world.
(22) Literally, 'you have made him sit on the floor', i.e. 'you
     have stolen everything down to his last chair.'
(23) The Thriae, who practised divination by means of pebbles
     (also called THRIAE).  In this hymn they are represented as
     aged maidens (ll. 553-4), but are closely associated with
     bees (ll. 559-563) and possibly are here conceived as having
     human heads and ******* with the bodies and wings of bees.
     See the edition of Allen and Sikes, Appendix III.
(24) Cronos swallowed each of his children the moment that they
     were born, but ultimately was forced to disgorge them.
     Hestia, being the first to be swallowed, was the last to be
     disgorged, and so was at once the first and latest born of
     the children of Cronos.  Cp. Hesiod "Theogony", ll. 495-7.
(25) Mr. Evelyn-White prefers a different order for lines #87-90
     than that preserved in the MSS.  This translation is based
     upon the following sequence: ll. 89,90,87,88. -- DBK.
(26) 'Cattle-earning', because an accepted suitor paid for his
     bride in cattle.
(27) The name Aeneas is here connected with the epithet AIEOS
     (awful): similarly the name Odysseus is derived (in
     "Odyssey" i.62) from ODYSSMAI (I grieve).
(28) Aphrodite extenuates her disgrace by claiming that the race
     of Anchises is almost divine, as is shown in the persons of
     Ganymedes and Tithonus.
(29) So Christ connecting the word with OMOS.  L. and S. give =
     OMOIOS, 'common to all'.
(30) Probably not Etruscans, but the non-Hellenic peoples of
     Thrace and (according to Thucydides) of Lemnos and Athens.
     Cp. Herodotus i. 57; Thucydides iv. 109.
(31) This line appears to be an alternative to ll. 10-11.
(32) The name Pan is here derived from PANTES, 'all'.  Cp.
     Hesiod, "Works and Days" ll. 80-82, "Hymn to Aphrodite" (v)
     l. 198. for the significance of personal names.
(33) Mr. Evelyn-White prefers to switch l. 10 and 11, reading 11
     first then 10. -- DBK.
(34) An extra line is inserted in some MSS. after l. 15. -- DBK.
(35) The epithet is a usual one for birds, cp. Hesiod, "Works and
     Days", l. 210; as applied to Selene it may merely indicate
     her passage, like a bird, through the air, or mean 'far
     flying'.
__
The Homeric Hymns in the Hello Poetry collection are provided by:
Online Medieval and Classical Library.
Source site: http://omacl.org/Hesiod/hymns.html